Takeaway from the EMS 3.0 Transformation Summit

A few weeks ago I went on a call for a 23 year old patient who had a toothache. She had had a tooth removed at a hospital-based dental clinic four hours earlier and wanted a ride to that hospital’s emergency department for the pain. She gathered her things, walked to the ambulance, sat on the captain’s chair, walked into the ed and was directed to fast track. The triage nurse nurse asked why we brought her there. I replied that we had no other choice.

Monday I attended the EMS 3.0 Transformation Summit. I left inspired with data from programs where patients like this would be directed to nurse, directed to a resource more appropriate than an emergency department and arrange transportation in a vehicle other than an ambulance.

Here are three things I took away:

1. Payment for healthcare is shifting from volume driven to value driven, regardless of who is president or changes in healthcare legislation.

Matt Zavadsky from MedStar provided some staggering numbers of the cost of healthcare in the United States and the cost of unnecessary ambulance transports to emergency departments. Even a 15 percent reduction would save 2 billion dollars in healthcare costs. He went on to describe how community paramedic programs are being reimbursed:

  • Fees to an insurance company for enrolling a member who is a high ED utilizer or at risk of  readmission after discharge from the hospital (CHF being the most common cause of readmission).
  • Fees to an insurance company for episodes of contact with a patient.
  • Payment for the number of enrollees living in an community paramedic coverage area.

Forward thinking services are making community paramedicine a sustainable model.

2. Community paramedic programs must include EMS services, physicians, patients and payers.

Stacy Elmer from Kaiser Permanente describe her experience finding a role for fire-department based community paramedic programs in her area to identify what patient populations would benefit.  She discussed how they used data for a needs assessment, such as readmission, frequent ED use, and frequent 911 use.  Dr. Bradford Lee from REMSA discussed how he had to meet with all of the cardiology groups in his area to agree on outcome goals for their patients seen by community paramedics. Zavadsky described how groups of health insurance companies needed to work together to arrange payment models. Community paramedic programs must grow from a good idea into identifying needs and establishing partnerships.

3. Our low education standards and lack of identity continue to plague us.

I was looking forward to John Clark and Walt Stoy’s presentation about the transformation of EMS education, but left the summit concerned.

Earlier in the day Dr. Mark Conrad Fivaz from Priority Solutions discussed developing telephone nurse-triage triage protocols. He reported that telephone medical advice, alternative destination, and alternative transportation were safe and lead to great cost savings, but only worked with nurses, not paramedics.

Dr. Bradford Lee from REMSA then discussed how his community paramedic program initially adopted the Minnesota community paramedic curriculum, but scaled it back into a 150 hours course, including clinical time. I thought about how I am now trying to cram Narcan, CPAP and supraglottic airways into a 150 hour EMT course REMSA’s program seems to be working, but I wondered how community paramedic content about disease management,  pharmacology social service could be taught in that time frame.

Clark gave an inspirational presentation about the value of board certification, which defines what a community paramedic, flight or critical care paramedic is, demonstrates their value to the community, and validates the education and professional commitment of paramedics.  Sinclair polled the audience about what they called themselves. One attendee identified them self as an EMR, and he asked if that stood for an electronic medical record. A nurse is a nurse and a physician is a physician, no matter their specialty or board certification. Everyone at an EMS summit in the UK would identify them self as a paramedic. We need to stop trying to educate the public about the difference between an EMT and paramedic, pick a name that does not include the word technician, and communicate our value.

Stoy presented about the innovative programs included in the University of Pittsburgh’s paramedic program, including rotations at clinics and dispensing medications to homeless people, but described how few of their graduates actually work as paramedics for very long, and that they developed pathways into accelerated nursing and PA programs.

Most striking was that when asked if the current education model was adequate, Stoy answered ‘No,” and one attendee raised their hand when the audience was asked if the current 1500 hour paramedic curriculum was adequate. I left wondering why nurses are able to safely triage patients over the phone but the average paramedic cannot safety do this after assessing a patient in person. Changing that would require a lot more unsexy education for paramedics.

Whatever you think of community paramedics, I left thinking that our current 911 response and ED transport model is not sustainable. Stoy pointed out that while major retailers were competing with each other, they never saw Amazon coming. With high out-of-pocket costs for patients with insurance for ambulance rides, and with Uber and Lyft delivering faster response times than many EMS services, we need to adapt. I left inspired by what some services have demonstrated is possible with community paramedic programs, but fear that our educational model and transient workforce will leave EMS even more marginalized.

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